Welcome!
Thank you for contacting Fournier Insurance Solutions.
The information collected from this questionnaire will help us
prepare a homeowner's proposal for you.
This will take approximately 10 minutes to complete.
Start
 
How did you hear about us?

 
Your name: *

 
Date of Birth: *

 
2nd Insured's name: *

If there is no additional insured, please input "none."
 
2nd Insured's Date Of Birth:

 
Day time contact phone number(s): *

 
Location Address: *

 
Mailing address, if different from location address:

 
How would you rate the service that our agency provides?

5 being the best





 
Years at Current Residence: *

 
If you have been at your residents less than 3 years, please provide prior address(es):

 
Your employer and occupation: *

 
Education Level: *


 
Marital Status: *


 
Do you currently have home owner's insurance? *

     
 
Current Insurance Company: *

 
Is your current coverage being non-renewed or cancelled, why? *

 
How long have you had your current coverage? *

 
Current Deductible: *

 
Dwelling Coverage? *

     
 
Liability Coverage? *

     
 
Special Personal Property? *


 
Do you currently have coverage on any of the following? *


 
Are you interested in obtaining coverage on any of the following? *


 
Have you had any claims in the last 5 years? *

     
 
Please list the date, type, and amount paid on the claim(s): *

 
The following questions pertain to information about your home.

 
Number of Stories: *

 
Year built: *

 
Is your home: *


 
Square footage: *

 
Foundation Type: *


 
Do you have a basement? *

     
 
What percentage is your basement finished/unfinished? *

 
Type of Roofing: *


 
Type of siding: *


 
Year roof was last updated or replaced: *

 
Year plumbing updated or replaced: *

 
Your electric box contains: *


 
Year electrical was updated or replaced: *

 
Auxiliary heat: *


 
Number of hearths: *

 
Number of Chimneys: *

 
Heat Type: *


 
Do you have a solar unit? *

     
 
Do you have central a burglar alarm? *

     
 
Do you have a central fire alarm? *

     
 
Do your doors have deadbolts? *

     
 
Do you have smoke detectors? *

     
 
Do you have a fire extinguisher? *

     
 
Distance to fire Hydrant:

 
Distance to Fire Station:

 
Number of Bathrooms and size: *

Example:  2-full, 1-1/2,  1-3/4
 
Do you have a pool? *


 
Do you have a hot tub? *

     
 
Please list number of decks or porches and their square footage. *

 
Do you have a car port? *

     
 
Do you have a garage? *


 
Number of cars? *

 
Do you own any animals? *

     
 
We like animals too! What type/breed of animals do you own? *

Please include breed and how many.
 
Do any of your animals have a bite history? *

     
 
Any Extra Features? *

Please select all that apply.

 
Are there any businesses being operated in the home?  If Yes, please explain. *

 
Mortgagee name: *

If you are unsure or do not have the information with you, please put "unknown."
 
Mortgagee address:

If you are unsure or do not have the information with you, please put "unknown"
 
Loan Number:

If you are unsure or do not have the information with you, please put "unknown"
 
Have you done any remodeling in the last year? *

     
 
Do you serve on any non-profit boards? *

     
 
Do you belong to a homeowner's association? *

     
 
Do you have any of the following:

Please select all that apply.

 
Do you own any of the following?

Please select all that apply.

 
Do you rent the home or other structures out to others? *

     
 
Do you provide home day care? *

     
 
Do you maintain an office in your home or provide private lessons? *

     
 
Do you maintain any samples or  articles for sale on your premises? *

     
 
Do you own any property used in your trade, business, or profession? *

     
 
Do you have a personal property inventory? *


Thank you {{answer_7762692}} for taking the time
to complete this questionnaire for a home policy proposal.
One of our agents will be contacting you soon.
FiS Home Page